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VA/Dod Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury

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VA/Dod Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF CONCUSSION-MILD TRAUMATIC BRAIN INJURY Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 2.0 – 2016 VA/DoD Clinical Practice Guideline for the Management of Concussion-mild Traumatic Brain Injury Prepared by: The Management of Concussion-mild Traumatic Brain Injury Working Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 2.0 – 2016 Based on evidence reviewed through March 2015 February 2016 Page 2 of 133 VA/DoD Clinical Practice Guideline for the Management of Concussion-mild Traumatic Brain Injury Table of Contents I. Introduction ............................................................................................................................. 5 II. Background .............................................................................................................................. 6 A. Terminology Conventions within this CPG ................................................................................. 7 B. Additional Educational Materials and Resources ....................................................................... 7 III. About this Clinical Practice Guideline ........................................................................................ 9 A. Methods ...................................................................................................................................... 9 B. Conflict of Interest .................................................................................................................... 12 C. Scope of this CPG ...................................................................................................................... 12 D. Highlighted Features of this CPG .............................................................................................. 12 E. Patient-centered Care .............................................................................................................. 13 F. Implementation ........................................................................................................................ 14 IV. Guideline Working Group ....................................................................................................... 15 V. Algorithms ............................................................................................................................. 16 A. Module A: Initial Presentation (>7 Days Post-injury) ............................................................... 17 B. Module B: Management of Symptoms Persisting >7 days ....................................................... 18 VI. Recommendations ................................................................................................................. 19 A. Diagnosis and Assessment ........................................................................................................ 22 B. Co-occurring Conditions ........................................................................................................... 27 C. Treatment ................................................................................................................................. 27 D. Setting of Care .......................................................................................................................... 39 VII. Knowledge Gaps and Recommended Research ....................................................................... 43 A. Diagnosis and Assessment ........................................................................................................ 43 B. Treatment ................................................................................................................................. 43 C. Care Delivery ............................................................................................................................. 43 Appendix A: Guideline Development Methodology ........................................................................... 44 A. Developing the Scope and Key Questions ................................................................................ 44 B. Conducting the Systematic Review .......................................................................................... 45 C. Convening the Face-to-face Meeting ....................................................................................... 72 D. Grading Recommendations ...................................................................................................... 72 February 2016 Page 3 of 133 VA/DoD Clinical Practice Guideline for the Management of Concussion-mild Traumatic Brain Injury E. Recommendation Categorization ............................................................................................. 75 F. Drafting and Submitting the Final CPG ..................................................................................... 77 Appendix B: Clinical Symptom Management ..................................................................................... 79 A. Appendix Contents ................................................................................................................... 79 B. Introduction .............................................................................................................................. 79 C. Co-occurring Conditions ........................................................................................................... 80 D. Headache .................................................................................................................................. 81 E. Dizziness and Disequilibrium .................................................................................................... 90 F. Visual Symptoms....................................................................................................................... 93 G. Fatigue ...................................................................................................................................... 94 H. Sleep Disturbance ..................................................................................................................... 94 I. Cognitive Symptoms ................................................................................................................. 97 J. Persistent Pain .......................................................................................................................... 98 K. Hearing Difficulties ................................................................................................................... 98 L. Smell (Olfactory Deficits) .......................................................................................................... 99 M. Nausea ...................................................................................................................................... 99 N. Changes in Appetite .................................................................................................................. 99 O. Numbness ............................................................................................................................... 100 Appendix C: Mechanism of Injury ................................................................................................... 101 Appendix D: Evidence Table ........................................................................................................... 104 Appendix E: 2009 Recommendation Categorization ........................................................................ 108 Appendix F: Participants List .......................................................................................................... 122 Appendix G: Acronym List .............................................................................................................. 124 References ....................................................................................................................................
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